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(07) 4942 5111
(07) 4954 4477
(07) 4941 7930
Hope For Little Fighters
Terms and Conditions
Emergency Dental Service
Lip & Tongue Tie
Sedation and General Anaesthetic Dentistry
Clear Aligners Special Deals
Gift Voucher – Smile All Year
Complimentary Happy gas
FREE Smile Simulation
New Patient Experience – Mackay
Dr Hany – Principal Dentist
Dr Paul – Dentist
Dr Xin – Dentist
Dexter – Our Therapy Dog
Snoring Laser Care
Job Application Form
Oral Health Therapist
OHB Medical for Children aged 18 months to 17 years
Child & Parent Details
Patient First Name
Patient Last Name
DD slash MM slash YYYY
Please select from drop down box
Which location is managing your booking?
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent 1 Relationship to Child
Parent 2 First Name
Parent 2 Last Name
Parent 2 Relationship to Child
Mobile Phone or best contact number
Who can we thank for referring you to us?
e.g. another parent, health professional, google, social media, radio, billboard etc.
This information is collected to understand your child’s growth, development and health.
Name of GP / Medical Centre attended
No known medical concerns
ADD/ADHD or other
Autism or other Spectrum Disorder
Bladder /Bowel Problems
Chicken Pox (active)
Please check any boxes that apply
Any other medical condition not listed we should know about?
Is your child currently under the care of a paediatric team for any reason?
If yes, please provide Specialist's name, Profession & name of practice
Any medications or supplements taken by your child?
If Yes - please advise what medication/supplement your child takes
Dust/ & or Pollen
No known allergies
Please advise of any allergies not listed
Does your child experience any of the following conditions?
Food intolerances (textures/solids)
Skin conditions like dermatitis or eczema
Upper respiratory infections
If your child does have allergies or other airway issues, have you consulted with any health professional?
If yes, please provide which Health Professional, when & proposed support
Has your child had any surgery?
If yes, please briefly advise what type of surgery and when
Does your child have any special needs we should be aware of?
If yes - please briefly explain
Immunisations - Are they up to date?
Is this your child's first visit to the dentist?
Yes 1st visit to any dentist
If your child has been seen at another dentist, we can arrange to have their records transferred over. Please advise who and when approximately
**Especially if any dental x-rays were previously taken, as Oral Health & Beyond will only take diagnostic images if clinically necessary.
What is the reason for your visit with us?
Dental emergency -pain &/or trauma
Dental Treatment under sedation required
Lip and Tongue Tie assessment
Has your child ever had an unfavourable dental visit?
How well does your child tolerate dental/medical care?
How many times a day is your child brushing their teeth?
1 with parental assistance
2 with parental assistance
Has your child ever had any dental x-rays taken?
If clinically required, dental x-rays are an important part of diagnosing your child's dental health. Oral Health & Beyond uses very low dose radiation equipment. This will be discussed if needed, as your consent is required.
Is there a history of dental decay or missing teeth in the family?
Oral Restrictions - Lip and Tongue Tie
Has your child ever been examined for oral restrictions of the oral muscles such as tongue/lip tie?
If yes, by whom?
Has your child previously had a lip & or tongue released?
Yes - snipped at birth by Paediatrician
Yes - later Private clinic
If private clinic, may we ask where?
Diet & Feeding
As an infant, how was your child fed?
Breast no issues
Breast with issues
Bottle Expressed Milk
Tube /syringe fed
Did you experience issues feeding your child as an infant?
No - was able breastfed no issue
Yes - struggled or unable to breastfeed
Bottle fed by choice
Did/does your child have any of the following issues with eating?
Fussy about textures/solids
What foods does your child like for a snack?
What does your child drink on a daily basis?
What does your child drink from?
Sleep & other developmental questions
Has your child ever experienced any of the following?
Co-sleeping with parent/s
Difficulty falling asleep
Difficulty staying asleep
Gasping for air
Restless sleeping / Excessive movement during sleep
Does not seem to be well rested after sleep
Constant fatigue during the day
Sleeping with mouth open
Attention deficit disorder symptoms
Difficulty waking up
Poor school performance/behaviour
Sleep with head tilted backwards
Bodywork - Has your child ever been assessed/treated by a Chiropractor, Bowen Therapist or the like?
If yes with whom and does your child still have bodywork on a regular basis?
Speech - Do you have any concerns in regards to your child's speech?
Has your child had any Speech Therapy?
Yes - please add by whom in other box
Habits -Did or does your child have any of the following habits?
Developmental - Have you had any concerns in regards to your child's weight gain?
Is your child reaching milestones within anticipated time frames?
No - please detail in other box
I submit this medical form on behalf of my child & I understand that this information is correct to the best of my knowledge. I understand it will be held strictest confidence and only used to improve the quality of service my child receives.
I understand I am financially responsible and that payment is due on the day of my child's appointment.
*Health Funds - I understand that my health insurance & rebates received are the responsibility of my insurer and myself.
*CDBS - I understand it is my responsibility to advise if my child is eligible for benefits, limits to available funds apply and that not all dental services are covered under this government incentive. I will sign the required CDBS consent form as required.
Acknowledgement - Photographs/Marketing
Yes I consent
No images of my child are to be used for social media
Please ask my consent prior to any photos being taken
Photos are routinely taken for dental/myofunctional, research & education purposes and in most cases these are for your child's dental records & kept on file only. Oral Health & Beyond does sometimes takes fun photos for use on social media, but will always ask your permission. I understand that if photos of my child are used, first name may be used but all other identifying information will be kept confidential. I do not expect compensation, financial or otherwise for the use of images.
Name of Parent/Guardian
DD slash MM slash YYYY
(07) 4517 3344
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